Healthcare Provider Details

I. General information

NPI: 1376521369
Provider Name (Legal Business Name): STACEY BRYANT NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 05/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 GOVERNORS AVE HALLMARK HEALTH SYSTEM, INC.
MEDFORD MA
02155-1643
US

IV. Provider business mailing address

170 GOVERNORS AVE HALLMARK HEALTH SYSTEM, INC.
MEDFORD MA
02155-1643
US

V. Phone/Fax

Practice location:
  • Phone: 781-306-6000
  • Fax: 781-306-6085
Mailing address:
  • Phone: 781-306-6000
  • Fax: 781-306-6085

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number215935
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: